Download HEMS CQI Training (2)

HEMS C Q I Training
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OVERVIEW
Continuous Quality Improvement (CQI) is a very important part of
Emergency Medicine today, and in the future.
CQI is an on going process, whose sole purpose is to improve quality.
This is done many ways.
– It is conducted privately, because CQI are not discoverable in court, if the
rules are followed. CQI Must is an organized program.
– All CQI documents should be marked as CQL Everything discussed in a
CQI Meeting stay in the Meeting.
– Personal identifying information should be removed. This includes the
patient's name, and personnel's name.
– Personnel should be identified by a number or code, which is only known to
that person and the QC'I Director.
HEMS C Q I Training
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Topic is chosen by physician director, at
least 1 per six month report.
Current topics:
AMA,
Child Birth,
Medications,
Airway,
Spinal Indicators,
Documentation
Communicable Disease
IV's,
Mental Status Changes,
Chest Pain,
Splinting,
Priority #1
Trauma
HEMS C Q I Training
INDICATORS
Indicators, markers, monitors all mean, basically, the same thing,
HEMS has already chosen a list of indicators, for each CQI topic.
QCI Reports: 2 reports are required every year. Work with you
physician director to review and complete.
All QCI Reports contain 4 elements
1
2.
3.
4.
Data
Analysis of Data
Summary of Data
Plan for future
HEMS C Q I Training
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1.
DATA
– For each QCI topics there are data collection sheets.
– Each sheet lists the dictator for each study.
– How many Runs do you need to review?
– Depending on the topic and the company size will make a difference in data
collection. For example a large company may have 1000 chest pain runs in :1
month, and a small company may only have 10 Runs in 6 months. So, the
smaller company will need to review all its runs, in order to get a larger enough
sample size, and the large company will only need to a percentage of the runs. If
using sample system, you need to pull enough runs , so that you get at least a
few chart from everybody. If your sample size is very small, like with OB, a
review course may be substitute, but only with the approval the physician
director.
HEMS C Q I Training
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2.
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3.
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4.
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DATA Analysis:
Adding up all the data collection points and comparing it against -the threshold and other
companies and individuals within your own company, or prior reviews.
DATA Summary:
How did you do? Did you meet and surpass the goal and where did you fail?
Plan for the Future:
After your review and summary, what are your plans to correct and problems that you
discovered, i.e. training program, peer review, and repeat markers in six months, or
everything was good and no further review is indicated
HEMS C Q I Training
Participating Agency _______________________________
Counties represented ______________________________
Sort as indicated by the Wayne County Protocols
Occurrence
Performance
Percent
Threshold
95%
95%
95%
i.e. " performance number" is the number of deviations that were documented.
Completed By:
Report Date:
HEMS C Q I Training
HEMS Quality Improvement
Clinical Indicators
EMT-B
EMT-S
EMT-P
Title: Splinting
Standard: The patient with a suspected Fracture, will be provided assessment, treatment and transport
Reference: This standard may be referenced to the SEMRP splinting procedure
Specific clinical indicators
Mechanism of Injury:
1. How did the patient injury occur
A. Fall assault, mva
2. Impact description
Assessment:
3. Extremity fracture above hand or foot
4. Motor and /or sensory deficit
5. Deformity opened or closed
Treatment:
6. Treatment by another HCP prior to arrival is documented
7. Immobilization:
a. immobilization not indicated
b. pt. injury immobilized prior to arrival
Motor/ sensory pulse assessed after immobilization
9. Motor sensory/pulse at time of TOT ED staff
10. Any deviations from standard care is documented
Total
HEMS C Q I Training
Continued
(1) Total number should remain constant 4-10
(2) The total of deviations should equal those patients who did not get the expected performance. The
Treatment # 7 only
Methods: Data collected through retrospective run review
Screen: Review Priority 2 & 3 patients for a 6 months period
Audit start:
Comments/ Audit exceptions:
Audit completed:
HEMS C Q I Training
HEMS EMS SYSTEM
INTEGRATED AGENCY/SYSTEM QUALITY IMPROVEMENT (Ql) PLAN
CONFIDENTIAL MONITORING AND EVALUATION REPORT
This document is part of the professional/peer review process of the Wayne County Medical Control Authority and the generating EMS
provider agency. This document, any attachments (whether or not specifically labeled QA/Ql material), and any records, documents, data,
knowledge or discussions involved in the preparation and/or review of this document are confidential, not public record, and not subject to
subpoena subject to one or more of MCL 331.531, 331.532, 331.533, 333.20175, 331.21513, 331.21515 and other State and Federal laws.
Unauthorized duplication, distribution, or disclosure is prohibited.
EMS AGENCY: _____________________PERIOD REPORTED:____________________________________
AREA OF EMPHASIS:: _____________________________________________________________________
INDICATOR 1: ____________________________________________________________________________
INDICATOR 2: ____________________________________________________________________________
THRESHOLD: ____________________________________________________________________________
FINDINGS
CONCLUSIONS
RECOMMENDATIONS/
FOLLOW-UP/ EVALUATION OF
ACTIONS TAKEN
ACTIONS TAKEN
SIGNATURES
REPORT PREPARED BY: ______________________________________TITLE: _____________________________DATE: _____________
(TRAINING OFFICER OR OA LIAISON)
CHIEF/DIRECTOR OF AGENCY: ___________________________________________________________________ DATE: ______ ______
PHYSICIAN ADVISOR: ___________________________________________________________________________ DATE: _____________
HEMS C Q I Training
HEMS QUALITY IMPROVEMENT
CLINICAL INDICATORS
Paramedic-Specialist-EMT-B
Participating Agencies: _______________________________
Counties Represented: ______________________________
Title:
Combitube insertion - Adult patients 16 yrs. and older
Standard: Combitube insertion- will be established to secure and maintain a patent airway in specific pre-hospital
patients as indicated by the Wayne County Protocols
Reference: This standard may be referenced to the SEMRP Airway Management/Oxygen Procedures
Specific Clinical Indicators
Totals
Occurrences
Performance Percent
1. Combitube insertion must occur in a patient with a compromised airway:
and ET intubations n/a or unsuccessful)
a. Cardiac Arrest
b. Unconscious
c. Decreased LOC with GCS < 8
d. Severe respiratory compromise
(patients indicated and patients attempted, not number of attempts)
(indicated)
(attempted)
1 a. Combitube must occur in a patient with a compromised airway:
a. Cardiac Arrest
b. Unconscious
c .Decrease LOC with GCS<8
d. Severe respiratory compromise
(patients indicated and patients attempted, not number of attempts)
2. Combitube insertion occurs within 2 attempts
(indicated)
1 of 2
Threshold
95%
(success)
95%
95%
HEMS C Q I Training
3a. If the Combitube is not established. Assist ventilations as indicated
until the patient has arrived to the receiving facility
(This total indicated should equal number of unsuccessful Combitube insertions)
(please note the exceptions such as pediatrics)
Bob. If Combftube insertion is established, assist ventilations as indicated
until the patient has arrived to the receiving facility
(patients Combitube attempted and patients with attempted and success)
4. Advanced airway insertion must occur with verification of initial
tube placement by auscultation and C02 detector and receiving physician
(total successful Combitubes)
5. Verification of correct tube placement following any patient movement
(total successful Combftube insertions)
6. The combitube is secured and tube depth is marked
(total successful Combitube insertions)
(indicated)
95%
(attempts)
(success
number)
Methods:
Screen:
Audit due:
Comments/ Audit exceptions:
Data collected through retrospective run review
Review Priority 1 patients until 25 patients can be entered into audit
Audits Completed:
(attempted)
Summary Report Date:
(success)
95%
100%
90%
100%
HEMS C Q I Training
CQI INDICATOR: AMA Documentation Compliance
HEMS Protocol: Patient Refusal of Care or Transportation to a Hospital
On scene when an Emergency may still exist:
If a patient or a minor patient's family refuses care or ambulance transportation to the hospital:
1. Explain indications for transport.
2. Explain possible complications that could arise without transport.
3. If any treatment procedures have been initiated, contact Medical Control. Clearly explain to
all concerned the wishes of the physician providing medical control.
4. Do not initiate any patient care after ambulance transportation is refuse. Obtain medical
control clearance to leave the scene.
HEMS C Q I Training
CQI INDICATOR: AMA Documentation Compliance
HEMS Protocol: Patient Refusal of Care or Transportation to a Hospital
On scene when an Emergency may still exist:
If a patient or a minor patient's family refuses care or ambulance transportation to the hospital:
5. Document the discussion with and obtain names, addresses and telephone numbers of all witnesses on the
Ambulance Report Form and request that it responsible individual sign the Service Refusal Statement on
the Report Form. If the patient refuses to sign the Statement of Refusal, make every effort to obtain
witness signatures.
6 Document on the run report any witnesses to the refusal.
7. Public Act 179, Section 20969- This part and the rules promulgated under this part do not authorize
medical treatment for or transportation to a hospital of an individual who objects to the treatment or
transportation. However, if emergency medical services personnel, exercising professional judgment,
determine that the individual's condition makes the individual incapable of competently objecting to
treatment or transportation, emergency medical services may provide treatment or transportation despite
the individual's objection unless the objection is expressly based on the individual's religious beliefs.
HEMS C Q I Training
CQI INDICATOR: AMA Documentation Compliance
HEMS Protocol: Patient Refusal of Care or Transportation to a Hospital
Discussion:
Patients who refuse emergency medical care present the EMS system with a wide variety of challenging
situations. The problem of refusal of care arises because health care providers must balance the
autonomy of the patient against the interests of the State in maintaining its citizens' life and health.
Patient autonomy requires that the patients be allowed to refuse any care that they find objectionable, for
whatever reason. However, the state has an interest in preserving life; of protecting the lives of innocent
third parties, such as a fetus, children, "incompetents" and other dependents; and of preventing injuries
to third parties.
The legal issues are protection from liability related to negligence lawsuits involving patients who have
refused care and subsequently suffered a poor outcome, or inappropriate use of restraint and legal action
based on battery or false imprisonment.
HEMS C Q I Training
CQI INDICATOR: AMA Documentation Compliance
HEMS Protocol: Patient Refusal of Care or Transportation to a Hospital
Balancing these two competing interests is the challenge in managing patients who refuse care.
A patient's right to be informed and give consent for any medical treatment and transportation is a
standard part of medical care. Informed consent includes disclosure or the nature of the disorder; the
proposed intervention; the likely benefits, risks, and discomforts; the possible alternatives: and the risk
of receiving no treatments. State courts use one of two basic standards that dictate the amount and type
of information that must be communicated to provide an informed consent or refusal.
1 . Reasonable medical practitioner standard: The quality and detail of the information given to patients
that would be imparted by a "reasonable practitioner" with their training and experience under the
same or similar conditions.
2. Reasonable patient standard: A consent or refusal is informed if that decision is one that "a prudent
person" in the patient's position would make if adequately informed of all the significant perils.
The autonomy interests of the patient who refuses care can be addressed by explaining and documenting
the risks, benefits, alternatives, and allowing the patient to make an informed consent.
HEMS C Q I Training
CQI INDICATOR: AMA Documentation Compliance
HEMS Protocol: Patient Refusal of Care or Transportation to a Hospital
Patients who cannot understand all the ramifications of the refusal cannot make an informed refusal of
care. These include patients with;
1 . Intoxication, hypoxia, acidosis, or any metabolic derangement.
2. New change in mental status
3. Dementia (surrogates may make decisions, expect in some emergency situations)
4. Suicidal or homicidal ideation or intent.
5. Any organic brain syndrome that prevents them from acting in a manner that is protective of
their life interests.
Refusal of care has a shifting continuum of severity and standard of competency. This is a very gray
area. The location on the continuum depends on the severity of the illness, the urgency of treatment
required, and the ability of the patient to understand their choices offered and come to a decision. Minor
medical problems allow for greater autonomy to refuse. Conversely, the medical care provider has a
duty to provide a more in-depth discussion and documentation for medical problems of increasing poor
outcome potential. The patient must be informed of the right to reinitiate medical care at anytime if they
change their mind.
HEMS C Q I Training
CQI INDICATOR: AMA Documentation Compliance
HEMS Protocol: Patient Refusal of Care or Transportation to a Hospital
Patients who cannot understand all the ramifications of the refusal cannot make an informed refusal of
care. These include patients with;
 The patient who refuses care must first have the capacity to understand the ramifications of the
refusal. Capacity can be summarized into determination of orientation and judgment. Some form of
determination and documentation of capacity, not competency that is a legal determination, must be
applied to those patients who desire to leave against advice. There is no standard test required or
definitive series of formal mental status tests.
 Patients must be oriented to person, place, and time and be able to engage in extended conversation
about their illnesses and treatment goals. This automatically excludes patients who are uncooperative
and non-communicative, or who have a clearly altered mental status. See "altered mental status
protocol".
HEMS C Q I Training
CQI INDICATOR: AMA Documentation Compliance
HEMS Protocol: Patient Refusal of Care or Transportation to a Hospital
Special Categories of Patients Who Refuse Care:
1.
Psychiatric patients: They should be presumed to be competent to refuse care, and their capacity
to refuse should be determined as previously described. Patients who refuse a medical screening
exam must be held against their will until they allow either treatment or formal mental screening
exam evaluation. Suicidal or homicidal patients by thought or attempt do not have capacity to
refuse. A mentally ill patient in community residential treatment may be signed against advice to
a facility staff member who can vouch that the person is at baseline and will assume
responsibility for supervising the patient. The staff member can sign the AMA form for the
patient and agree to return if any deterioration occurs.
2.
Alcohol Intoxicated Patients: These patients are difficult to evaluate because they present with a
set of complex medical and social problems and frequently have an altered mental status.
Alcoholic and alcohol impaired patients are prone to head and neck injuries and frequently
present with hidden or atypical signs and symptoms of their injuries. They are a significant risk at
misdiagnosis and should be considered a high-risk patient. Assume the intoxicated patient does
not have the capacity to consent to or refuse treatment and has a life-threatening problem until a
complete patient evaluation and capacity determination can be made. This is a judgment call and
requires significant documentation of capacity to understand all recommended medical care
recommendations, alternatives, potential complications and right to reinitiate care if they change
their mind.
HEMS C Q I Training
CQI INDICATOR: AMA Documentation Compliance
HEMS Protocol: Patient Refusal of Care or Transportation to a Hospital
Special Categories of Patients Who Refuse Care:
3.
Violent Patients: Violent patients should be treated with reasonable therapeutic restraint. They
often refuse care. There is a correlation between violence and organic brain syndrome. The AMA
should not be used to get rid of these patients. EMS practitioners have no duty to remain in harms
way to treat a violent patient. If the patient cannot be restrained for a short time, police should be
summoned to assist restraint of the patient as required. If the patient elopes before safe restraint
can be accomplished, document the fact that the patient was not restrained because of fear of harm
to the EMS practitioner. The patient should be allowed to "escape" and the police should be
notified and told that the patient may be a threat to self or others.
4.
Religious Objections: The general rule is that competent adult patients have a right to refuse any
treatment on any grounds including religious. The counts have held that any refusal of lifesaving
medical treatment must be contemporaneous and informed. Any refusal of care on religious
grounds presents very difficult medical-legal issues and should occur with direction of medical
control.
HEMS C Q I Training
CQI INDICATOR: AMA Documentation Compliance
HEMS Protocol: Patient Refusal of Care or Transportation to a Hospital
Special Categories of Patients Who Refuse Care:
5.
Refusal of care for a minor: Unless the minor is emancipated, or is a " mature minor'% or has one
of the special conditions covered by state law, a minor is not cognitively or legally capable of giving or
refusing consent for medical treatment. Problems typically occur when an adolescent refuses care.
Initiation of care is a gray area if no parent or legal guardian can be found. The more life threatening the
medical emergency, the more care that can be provided under the scope of what a reasonable person
would provide if consent were available. When a parent or legal guardian refuses medical care for their
child, the state and federal courts support parental control over the basic matters affecting children.
When parental actions have resulted in inadequate medical care, the courts have stepped in to decide
between parent's wishes and physicians' concerns. Under the doctrine parens patriae, the state represents
the best interests of the child and will not allow a child's health to be seriously jeopardized because of
the parent's convictions. Parents do not have the authority to forbid saving their children's lives. Courts
invariably rule in favor of physicians who claim that parents are denying standard medical care for their
children. If parents withhold consent and there is a threat to a child's life, the EMT should contact
medical control for direction and be prepared to take protective custody based on child neglect. Explain
to parents that this is a medical obligation under law. The EMT is protected from civil and criminal
liability under the child abuse and neglect statutes. If there is no life threat and no potential for serious
impairment the parents' refusal should be respected after consultation with medical control. The refusal
should be informed and well documented. It should be noted, in the past 30 years, no cases have been
reported where a parent successfully sued a medical practitioner for providing non-negligent care to an
adolescent without parental consent.
HEMS C Q I Training
CQI INDICATOR: AMA Documentation Compliance
HEMS Protocol: Patient Refusal of Care or Transportation to a Hospital
Special Categories of Patients Who Refuse Care:
KEY POINTS:
1.
Patients who have capacity for decision-making have the right to refuse care under many
situations.
2.
EMT's must understand the principles of testing a patient for capacity and apply this principle to
the situation of a patient refusing care.
3.
Patients who lack capacity to refuse care may be treated, transported, and restrained if necessary
for needed medical evaluation and care.
4.
Patients who possess capacity and refuse care should have this capacity documented, be signed
out AMA, and given proper discharge instructions.
5.
Most situations of refusal on religious grounds are appropriate, except when the decision involves
a minor or pregnant women.
HEMS C Q I Training
AMA Charts:
1.
Provide and document education of your agency according to AMA education.
2.
Evaluate all AMA runs that are available (max 25) for proper documentation prior to education,
and follow all runs subsequent to the education.
3.
Evaluate runs for the documentation involving:
A. Capacity
i. A/0 x 3, extensive conversation about their illness and treatment goals and
recommendations given with understanding.
ii. Risks, benefits, alternatives, and ability to reinitiate care must be discussed, understood
and documented to the best ability of the medical caregiver.
iii. Monitor for potential signoff of patients who are high risk.
1. Intoxication
2. Psychiatric
3. New mental status change
4. Dementia
5. Organic Brain Syndrome
B. Special Category Patients
i. Psychiatric
ii. Alcohol Intoxicated
iii. Violent or aggressive
iv. Religious Objection
v. Refusal of Care for a Minor
I am looking for significant improvement and understanding of this high-risk patient encounter.
Continue sample review of documentation for spot check to maintain gains made by chart
documentation review QA. 25 charts.
HEMS C Q I Training
1 of 2
HEMS Quality Improvement
Participating Agencies:
Clinical Indicators
EMT-B
EMT-S
EMT=P
Counties Represented:
Title: Chest Pain Of Cardiac Origin
Standard: The Patient With chest pain, suspected to be cardiac in origin, will be provided assessment,
treatment nt
and transport, as indicated by the Wayne County Protocols
Reference: This standard may be referenced SEMRP protocol for Chest Pain Patents
Total
occurrence
Specific Clinical Indicators
performance
Predisposing Events/ Hx of Present Illness
I. Predisposing event, activity, or enviromental exposure is
documented.
2. Time Of Onset
3. Patient attempts to alleviate pain
;a. Patient took own prescribed medication
4. Assessment: Quality of pain (dull,stabbing,etc)
5. Radiation of pain
6. Severity of pain (quoted description of 1-10 scale)
7. Patient position
8. Skin color, temportature, moisture (all 3)
S. Breath sounds
10. Nausea vomiting, JVD
I 1. Peripheral edema present
12. BP prior to NTG given
13. Treatment: Treatment PTA by other HCP documented
14. Oxygen Administration *
Percent Threshold
95%
95%
95%
HEMS C Q I Training
a. Administered prior to arrival
b. Within 2 min of arrival
c. >2min but < 6min
d. >5 min but <10min
e. > 10 min
15. EKG is obtained
First IV is attempted:
a. Administered prior to arrival
b. Within 5 min of arrival
c. >5 min but < 10 min
d. >10 min but < 15 min
e. > 15 min
17. ASA administered prior to arrival
a within 5 minutes (of arrival at pt.)
18. First Nitro given:
a. Nitro is not indicated in this patient
b. Nitro given prior to arrival
c. within 5 min of ALS arrival
d. >5 and < 10 minutes
e. >10 and< 15 min
f. greater than 15 minutes
19. If Nitro -oven without IV started, Hx of nitro use, BP
(Systolic > 120 or above)
20. NTG given every 3-5 min, until pt pain free up to 3 NTG or
until contraindicated
21. BP is checked after each NTG or MS is administered
22. Scene time is
a. <10 min
b. >1 0 min but < 20 min
c. >20 min but < 30 min
d. > 30 min
23. If pain present after 3 NTG, MS is requested
24. Effects of treatment are documented
25. Any deviation from standard of care is documented
100%
95%
95%
HEMS C Q I Training
* All EMT-B participate up to line 14 EMT-S up to line 16 and EMT-P continue to line 25
* Variation of 2 minutes is allowed
1. Total number should remain constant 1-23
2. Total for a,b,c,d should equal total number in audit.
3. The Total number is the total deviations . (When performance did not occur as indicated.)
This indicator Performance number is number of deviations documented.
Methods: Data Collected through retrospective run review.
Screens,: Review Priority 1 & 2 chest pain pt's until 26 cardiac chest pain pt's can be entered
into audit
Audit Due:
Summary Report Date
Audit Completed:
1 of 2
HEMS Quality Improvement
Clinical Indicators
Participating Agencies
EMT-B
EMT-P Counties Represented
EMT-S
Title: Obstetrical / Child Birth/ APGAR Chart
Standard:
The pregnant patient with suspected miscarriage, delivery will be provided with assessment treatment and
transport, as indicated by the Wayne County Protocols
Reference: This standard may be referenced to the SEMRP protocol for Obstetrical/ Child Birth
Specific Clinical Indicators
Total
Occurrence Percent
Threshold
Performance
1) Predisposing events G- P- Ab2) How many gestational weeks is the patient
95%
3) Last menstrual period
Assessment:
4) Vaginal Drainage
a. has water broke, vaginal bleeding, discharge (mucus plug)
5) Pain assessment
a. Contractions ( time duration)
95%
b. Back pain
c. urge to -have a bowel movement
Treatment:
1) Administer High Flow 02
2) consider placing pt left lateral recumbent if hypotensive
3) Is baby delivering (crowning)
a. Suction baby’s mouth and nose as soon as head is
delivered
b. Check to see if cord is wrapped around neck
100%
if so attempt to unwrap the cord, if unable clamp cord and
cut immediately
c. Double clamp cord 4" from baby and cut between the clamp
d. Dry baby, keep warm, place baby with mother during
transport
e. Externally massage uterus until placenta is delivered
95%
don't attempt to manually remove placenta)
record the time of birth
HEMS C Q I Training
Baby's assessment APGAR Score:
0
Pulse
blue,pale
Grimace
absent
Activity
none
Resp
flaccid
absent
1
2
body pink pink
hands blue
< 100 > 100
grimace cough, cry
some active
weak, slow good
4. Effects of all treatments are documented
5. Any deviation from standard of care is documented
All OB patients must be cleared to go to L&D unless otherwise directed by the ER DR.
1. -Total number should remain constant 1-5
2. Total for a,b,c,d,e,f should equal total number in audit
3. The total number is the total deviations (when performance did not occur as indicated)
100%
1 of 2
Title:
Spinal Injury Patient: MVA
Standard:
Spinal immobilization will be established to prevent further potential for injury in specific patients, as
indicated by the Southeast Michigan Regional Protocols.
Reference:
This standard may be referenced to the SEMRP Spinal Immobilization procedure.
Total
Occurrence/
Specific Clinical Indicators
Performanc
e
Mechanism of Injury:
1. a. Patient position before crash is documented.
b. Patient position after crash is documented.
c. Patient position upon arrival is documented. (1).
2. Seat belt use identified.
3. Air bag deployment (or not) identified.
4. Impact description (T-bone, rollover, etc.)
5. Area of external damage describe including windshield.
6. Area of internal damage.
Assessment:
7. Altered mental status
8. Evidence of intoxication
9. Extremity fracture above hand or foot
110. Motor and/or sensory deficit
11. Spine pain and/or tenderness
12. Motor / sensory / pulse evaluated X 4 extremities (prior to tx)
Treatment:
13. Treatment by other HCP prior to arrival is documented
14. Immobilization: (2).
a. Immobilization not indicated
b. Patient immobilized prior to arrival
c. If patient found sifting, KED applied
d. If patient found standing, immobilized from standing
Position
e. If patient horizontal, log-rolled onto LBB
15. Motor / sensory / pulse assessed after immobilization
16. Motor / sensory / pulse assessed at time of TOT ED staff
17. Any deviation from standard of care documented. (3).
Percent
Threshold
HEMS QUALITY IMPROVEMENT
CLINICAL INDICATORS
Agency_____________________
(1) Total Number should remain constant 12-16. (Exceptions: #14, should only be evaluated on
patients with position found documented, #12 May not be evaluated on patients already
immobilized - may be less than total number, # 13 May not equal total number of
patients.)
(2) Total of 14 a,b,c,d,e should equal total number of performance in # 1. (if Immobilization
provided PTA, method is not evaluated.)
(3) The total of deviations should equal those patients who did not get the expected performance.
The "performance number" is the number of deviations that were documented
(Treatment indicator # 14 only).
Methods:
Data collected through retrospective run review.
Screen:
Review Priority 2 & 3 patients for a 6 month period.
Audit start:
Comments / Audit Exceptions:
Audit completed:
Report date:
Title:
Spinal Injury Patient: Other than MVA
Standard:
Spinal immobilization will be established to prevent further potential for injury in specific patients, as indicated by the
Southeast Michigan Regional Protocols.
Reference:
This standard may be referenced to the SEMRP Spinal Immobilization procedure.
I
I
Specific Clinical Indicators
Mechanism of Injury:
1. Patient position upon arrival. (1).
2. Description of mechanism. (distance of fall, etc.)
Assessment:
3. Altered mental status
4. Evidence of intoxication
5. Extremity fracture above hand or foot
6. Motor and/or sensory deficit
7. Spine pain and/or tenderness
B. Motor / sensory / pulse evaluated X 4 extremities (prior to tx)
Treatment:
9. Treatment PTA by other HCP documented
10. Immobilization indicated by protocol: (2).
a. Immobilization not indicated
b. Patient immobilized prior to arrival
c. If patient found sifting, KED applied
d. If patient found standing, immobilized from standing
position
e. If patient horizontal, log-rolled onto LBB
11. Motor / sensory / pulse a ssessed after immobilization (3).
12 Motor / sensory / pulse assessed at time of TOT ED staff (3).
17. Any deviation from standard of care documented. (4).
Total
Occurrence/
Performance
Percent
Threshold
(1) Total Number should remain constant 1-9. (Exceptions: #10, should only be
evaluated on patients with position found documented.
(2) Total of 10 a,b,c,d,e should equal total number of performance in # 1.
(3) Total same as total for #10.
(4) Number should equal total patients minus total performance (equals the deviations).
This indicator performance number is number of deviations documented.
Methods:
Data collected through retrospective run review.
Screen:
Review Priority 2 & 3 patients for a 6 month period.
Audit started:
Comments / Audit Exceptions:
Audit completed:
Report date:
HEMS Quality Improvement
Clinical Indicators
Participating Agencies:
EMT-P
Title: Vascular access/Fluid Administration
Counties Represented:
I
Standard: Vascular access will be established and fluid administration will be provided t o to pre-hospital patients as indicated by Wayne County
Protocols Reference: This standard may be referenced SEMRP Medication Administration Procedures
Specific protocols
Specific Clinical Indicators
Total
occurance
performance
1. Vascular access will be obtained in pre-hospital patients
as indicated by specific protocols
(indicated) (attempted)
A. Vascular access will be obtained in pre-hospital patients
as indicated by specific protocols.
2. Vascular access will be maintained until the patient
arrives to the ER (a + b = success #)
B. Saline Lock in place
3. The proper rate for intravenous fluid administration will
occur
(saline locks not included)
4. The proper amount of intravenous fluid will be
administered
(indicated) (success)
Percent
Threshold
90%
success#
90%
success#2a
90%
success #
90%
1. Specific documentation on patency of IV must be present. " Transferred over to ER staff without change not acceptable"
2. For audit purposes for amount of fluid, "TKO", "Bolus" or "Saline Lock', as appropriate.
With use of Saline Lock, flush with 3ml up to I Oml Is appropriate.
TKO rate (25cc/hr) evaluated when flush for medications is not needed.
TKO rate < 50ml acceptable for patient care time < one hour. (may include flush)
3. All crew LID needs to be given when review is completed and a high attempt rate is seen with a low success rate that
crew member may need more IV training.
Methods: Data collected through retrospective run review
Screen:
Review 50 charts at random with IV start.
Audit due:
Comments/ Audit exceptions:
Summary Report date:
Title: Medication Administration
Standard: Paramedics may administer medications as permitted by Wayne County Protocols in specific
Pre-hospital patients
Reference: This standard may be reference SEMRP Medication Administration Procedures
Participating Agencies:
Specific Clinical Indicators
Counties Represented:
occurance
Total
performance
1.The medication that is indicated is administered
(Omissions)(Evaluating to determine medications indicated
and if that medication was given)
Percent
Threshold
(incicate (total meds
d)
administered
95%
2. The medication administered is indicated for the
patients condition
(Errors) ( Evaluating all medications given and determining
if medication was indicated)
3. The medication will be administered in correct dose
(total number of meds given)
4. The medication will be administered with correct frequency
of dose. (Each med repeated as needed per protocol)
6. The medication will be administered by the correct
(indicate Correct Meds
d)
100%
(indicate number correct
d)
100%
(Total
admin)
lumber correct
(total
adm
(number
correct)
95%
route.
95%
1. Review the condition to determine if a medication is indicated. Review to determine if the medication that is indicated was given.
Individual meds are counted. Do not count meds repeated. There may be more than one medication per patient 2. Review all
medications to determine if the medication was indicated. This indicator is looking for medication errors. "Total" is all of the meds
given. Performance is the total meds that were indicated. There is no true relation between the data ill #1 & #2 3. Review the total
number of meds given to determine if they were given correct dose. 4. Review each type of med given to determine if it was repeated as
needed, or as indicated by protocol. "Total number of meds not the number of individual meds. If medication is indicated to only be
given once ie, ASA then count in total and in performance. For audit reason allow 2 minutes variance.
Methods:
Data collected through retrospective run review
Screen:
Review 50 charts at random any meds given
Clinical Indicators
EMT-P Title: Altered Mental Status Standard: The patient with altered Mental Status will be provided assessment,
treatment and transport, as indicated by the Wayne County Protocols for Altered LOC Reference: This standard may be
referenced SEMRP protocol for Altered Mental status
Participating Agencies:
Specific Clinical Indicators
Counties Represented:
Total
occurance
performance
Percent
Predisposing Events/ Hx of Present Illness
1 - Predisposing event,activity,or enviormental exposure is
documented.
Threshold
95%
2. Time Of Onset
3. Pertinent Past Medical History Medications pt is taking
14. Assessment: Position patient found
5. Description of Level of Consciousness
6.Glasgow Coma Scale is evaluated
7.Skin color,temperature,moisture(all 3)
8. Peripheral motor and sensory status
9. Pupils
10.Signs of trauma are evaluated
I 1.Glucometer is used if avaliable
12.Treatment by other HCP prior to arrival is documented
13.Oxygen is administered per protocol
14. Medication(s) are administered according to protocol
when indicated
15. Response to any treatment is documented
16. Deviations from protocol are documented
Total number should remain consistent 1 -10
16. This total number is the total deviations This indicator Performance number is number of deviations documented
* All EMT-B and EMT-S participate in all except line #14
Paramedics will perform lines 1-16
Methods:
Data collected through retrospective run review
Screen:
Review Priority 1 & 2 Altered Mental Status Patients until 25 Patients can be entered into audit
I
Audit due:
Comments/ Audit exceptions:
Summary Report date: